Beyond Recovery: Exploring Growth in the Aftermath of Psychosis

1 Research Division, Institute of Mental Health, Singapore, Singapore, 2 Department of Psychosis, Institute of Mental Health, Singapore, Singapore, 3 Office of Education, Duke-National University of Singapore Medical School, Singapore, Singapore, 4 Neuroscience and Mental Health, Lee Kong Chian School of Medicine, Singapore, Singapore, 5 Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore

INTRODUCTION "I'm unraveling," I said to my psychiatrist. "What do you mean? Tell me more," she inquired. "I feel … my personhood is falling apart … like a ribbon coming undone, unraveled," I replied.
Haltingly, I added that I was treading between reality and delusions. I felt like at any moment, I was going to be swept away by the torrential outpouring of psychotic thoughts in my mind. I couldn't stop crying.
All my efforts at rebuilding my life after my first psychotic episode were coming apart. I was in pieces again. What will become of my future? I shuddered at that thought.
That was 5 years ago. After that second episode, I completed my doctoral thesis (1), defended my research to a panel of distinguished neuroscientists, and relocated home. After a 2-year stint as a peer support specialist at a tertiary psychiatric hospital (2), I joined its research department (3). My current research efforts endeavor to understand recovery and growth from first episode psychosis. Informed by my lived experience with schizophrenia, I am convinced that growth, in the aftermath of psychosis, is possible.
That growth happens in suffering is not a new idea. Friedrich Nietzsche's view on trauma-what does not kill us makes us stronger-is a well-known maxim. Most millennials in the Englishspeaking world would have grown up listening to Kelly Clarkson's hit song Stronger (What doesn't kill you). Any entomologist will tell you that only butterflies that have struggled out of their cocoons can fly. Traumatic experiences, uncomfortable as they are, play a central role in subsequent growth and development of a living creature. Post-traumatic growth (PTG) is the scientific study of this curious phenomenon in humans. Coined by Tedeschi and Calhoun in the 1990s, PTG is defined as "[the] positive psychological changes experienced as a result of the struggle with highly challenging life circumstances" (4).

Post-Traumatic Growth Entails Three Levels of Positive Change
In a bid to measure the perceived positive outcomes experienced by people with traumatic experience, Tedeschi and Calhoun conducted an extensive literature review (5). They identified three levels of positive changes experienced by people with traumatic experiences over time: intrapersonal changes, interpersonal changes, and suprapersonal changes.
Intrapersonal changes stem from a deeper understanding of one's limits and strengths (personal strength). Tedeschi and Calhoun described this positive change as being "more vulnerable, yet stronger" (6). That traumatic experiences could leave a person feeling the full extent of his or her fragility is not surprising. However, the paradox is the inner strength that one uncovers in the process of overcoming the obstacles tells of the hidden strengths and resources that he or she is previously unaware of.
Interpersonal changes come from stronger bonds with family and friends (relating to others). Crisis makes or breaks relationships. In times of trouble, a person may have friends or family members who abandon them. However, there may also be people who remain supportive of them. The disaster brought on by challenging life events prunes superficial connections and strengthens genuine relationships, resulting in a milieu filled with people who truly matter.
Suprapersonal changes are outward expressions of the intrapersonal and interpersonal changes. It goes beyond one's immediate personal life. It may involve a positive change in one's outlook in life and the development of one's spirituality (appreciation for life, new possibilities, and spirituality). This may include not taking life for granted, exploring new skills and interests in life, and having a more balanced view on spirituality and faith.
Based on these domains, the Post-Traumatic Growth Inventory (PTGI) was developed and validated in an initial sample population (5). Today, this inventory is used widely by researchers from different fields, on people with different kinds of trauma: survivors of natural disasters (7,8), sexual abuse (9), cancer (10), suicide survivors (11), and even psychosis (12,13). The five domains of PTGI include personal strength, new possibilities, relating to others, appreciation of life, and spiritual change (5). This growth happens only when the traumatic event causes significant psychological distress and nullifies the person's initial worldwide (i.e., the person's ideas and assumptions on the world were proven to be wrong) (4, 6).

Post-Traumatic Growth in Psychosis
Psychotic episodes are traumatic experiences. The symptoms of this illness-delusions, hallucinations, disorganized behaviors and more-can cause a lot of distress to its patients. In fact, many reported fear and anxiety during their episodes (14). A systematic review on post-traumatic experiences of persons with first episode psychosis estimated the pooled prevalence of posttraumatic stress disorder (PTSD) symptoms at 42%, and PTSD diagnosis at 30% (15). In Singapore, a study on patients recovering from first episode of psychosis estimated the prevalence of PTSD at 19.7% (16). Yet, two independent studies conducted in the UK and Canada suggested that posttraumatic distress may not be the sole outcome in the aftermath of psychotic episodes (12,17).
The British team built a framework for PTG from the recovery narratives of persons with psychosis and other serious mental health issues (17). Six themes were generated from the semi-structured interviews with mental health patients: selfdiscovery, sense of self, life perspective, wellbeing, relationships, and spirituality. The authors concluded that growth was a part of the recovery narratives of persons with serious mental health issues. The Canadian team published a mixed methods study on PTG in persons with first episode psychosis (12). Their qualitative analysis showed that besides distress from psychosis, the participants also experienced positive changes such as a stronger sense of self, more balanced view of religiosity, and improvements in health and personality.
Readers familiar with Tedeschi's work would find the findings from the UK and Canada teams reminiscent of the five domains in PTGI. Even though every participant in the studies has his or her unique trauma story, the positive changes that result from their experiences fall into more or less consistent domains. The PTG framework developed by Tedeschi and colleagues in the 1990s holds true today and could be applied in the context of mental health research.
Conceptually, PTG has been contrasted with resilience by Tedeschi and colleague (4). Both PTG and resilience have some similarities, as both phenomena encompass the idea of thriving in adversity. However, they are conceptually different. Resilience has more to do with a person displaying positive adaptation despite significant trauma or adversity (18). PTG postulates that a person becomes psychologically stronger because of a significant trauma or adversity (4). Even though the outcomes of resilience and PTG (namely positive growth and adaptation) may appear to be identical, the processes in which these phenomena develop may be different. Researchers of resilience suggested that resilience is an innate characteristic (18), while PTG is a process that may be facilitated by healthcare workers (6). Hence, PTG and resilience are related, but distinct concepts.
To date, most published studies on PTG in psychosis are at the descriptive level. Even though they have laid a foundation for the presence of growth after psychosis, they have yet to explore the mechanism(s) behind its occurrence, and its relationship with related concepts such as resilience and recovery.

Beyond Survival
The American survivor culture has shaped therapy goals for many people with traumatic experiences to move from a victim mentality toward a survivor mentality (19). While the initial identification of the person as a victim, and then as a survivor, serve their respective purposes for help-seeking and for overcoming the immediate psychological damage, Dolan (19) noticed that staying in the survivor mode was not sufficient for her clients to thrive. A lot of them live against the backdrop of a mild depressive state, even if they managed to regain some semblance of life. At the same time, she encountered some clients with a history of abuse, yet leading meaningful and fulfilling life against all odds. When she interviewed them, she noticed that they do not refer to themselves as victims, or even survivors of their past. They seemed to have created new identities-free from their past, more toward to their authentic selves. She proposed that working beyond the survivor mentality, carving out a new sense of self, was the missing key for many of her clients (19). This involves growing beyond a traumatic past toward thriving.

Implications of Post-Traumatic Growth on Mental Healthcare
The implications of these growth findings are tremendous. It could change the way one thinks about the trajectory of serious mental illness and change how one treats these issues in the clinical setting. In the last decades, research on recovery from serious mental health issues grew exponentially (20)(21)(22)(23). There is now a strong body of evidence that supports the notion of recovery from serious mental illness. That mental illness is not a one-way ticket into an abysmal depth of disability-but of recovery-is widely accepted by the community. However, the current understanding of the detriments brought on by mental illness, and the subsequent recovery, may be incomplete. Like Dolan's idea of victim-survivor-authentic self in trauma care, I would propose that there is more beyond recovery for persons with serious mental illness; that PTG is possible for them, because of the crisis that they went through during the condition. The seismic shift brought on by mental illness in a person's life may be viewed as a unique opportunity to reevaluate one's strengths and weaknesses, to strengthen bonds with people who truly matter, and to connect with a purpose larger than oneself. Thus, a psychiatric condition could be a trigger for psychological growth. However, this growth does not happen by chance. To catalyze it, new dimensions have to be added to the roles of mental health professionals. Instead of limiting clinical work to rehabilitation and recovery, intentional efforts could also be made to capitalize the patients' traumatic experiences with mental illness and turn it into a growth opportunity. The challenge remains for us to understand how growth may be facilitated after mental health conditions. Tedeschi and Calhoun proposed that cognitive rumination, coupled with appropriate self-disclosure and social support, produces a personal narrative shift in PTG (4). Janoff-Bulman (24) expounded on the importance of making sense of traumatic experiences in the development of PTG. There may be some hidden treasures waiting to be uncovered from the body of work on PTG that could be applied to mental healthcare practices.
Granted, not everyone who survives mental illness grows from the experience. It does not mean that PTG is reserved for the privileged few. In the context of mental healthcare, I believe that opportunities for growth need to be intentionally introduced into the recovery plans of persons with mental illness. To grow in the aftermath of a mental illness, a period of introspection, positive self-disclosure, and benefit finding needs to be injected into a person's life. Deeper insights into how exactly PTG develops after mental health conditions, and how mental health professionals can support their patients to achieve that, could bring existing mental healthcare services to greater heights.
Looking back, it is almost like the three psychotic episodes I have experienced were preparing me for the work that I do today. In many ways, I am expectant for the next 5 years. No longer do I shudder at the thought of my future, knowing that the psychological growth that ensued from my psychotic episodes has made me a stronger person.

AUTHOR CONTRIBUTIONS
YL conceptualized the manuscript and wrote the first draft. SV and MS gave intellectual inputs based on their clinical and research expertise on psychosis.